**4. Differential diagnosis of erotomania**

When an individual is recognized as having erotomanic delusions, the following disorders must be considered:


### **5. Course and prognosis**

The "pure" or monosymptomatic form of erotomania is the one which usually corresponds with the diagnosis of paranoia/delusional disorder. In the past this has been regarded as unremitting and associated with a poor prognosis, but there is no early evidence that, analogous to other subtypes of delusional disorder, the condition may respond well to neuroleptic treatment. When erotomania is a symptom of another psychiatric illness such as major mood disorder, schizophrenia or some form of dementia, the course of the phenomenon is that of the parent illness and the prognosis depends on the natural history and adequate treatment of that illness. It is also important to take into account the possible presence of mental handicap, and to consider that, at least in some cases, erotomania may be non-delusional in nature. All of this emphasizes, as always, the need for complete and detailed history-taking and mental status examination as well as careful physical examination. Unfortunately, as we already know, patients with delusional disorder are not always prepared to be cooperative in such investigations. In special circumstances, as, for example, in the forensic psychiatric field, where repeated harassment of one person by another, assault of a female by a male or statements about alleged sexual feelings or behaviours have occurred, great care must be taken with assessment. If the perpetrator has a subtle delusional illness, the facts may be very difficult to tease out, and his certainty may, as has been noted, in some ways seem more convincing than the victim's bewilderment and denial. Good collateral information is of the essence here, and the person doing the assessment should be aware that professionals in the past have themselves been drawn into a kind of folie a' deux situation when they have come to believe uncritically in the statements of a highly persuasive paranoiac, as well as being influenced by implied or overt threats of litigation.

**Complications of erotomania and comorbid conditions:** Erotomania can make the patients show risky and aggressive behaviour. Sometimes, this behaviour can also result in the person getting arrested for stalking or harassment. Very rarely,

#### *De Clerambault Syndrome: Current Perspective DOI: http://dx.doi.org/10.5772/intechopen.92121*

erotomania can also result in the death of either person. Erotomanic delusions may be a single symptom which is also known as primary or pure erotomania and classified as a delusional disorder as per the DSM-IV. It may also occur as a secondary or symptomatic erotomania as a part of an extensive psychopathology. It can occur in various mental disorders such as schizophrenia, mood disorder or organic brain disorder.

This syndrome has been described in both heterosexual and homosexual forms. Comorbidity with other rare psychotic conditions has been reported, particularly with the delusional misidentification syndromes, including Fregoli's syndrome. More cases of secondary in comparison to primary erotomania have been reported usually in the context of a schizophrenic illness. This disorder has been often associated with bipolar disorder. It has been found to be associated with other conditions like anxiety disorder, drug or alcohol dependence, eating disorders and attention deficit hyperactivity disorder.

#### **6. Treatment and management**

The prognostic factors vary from person to person, and the ideal treatment is not completely understood. Though it has been seen that those patients who are having this syndrome along with some major psychiatric disorder like schizophrenia show poor prognosis as the complexity of the symptoms of both the disorders makes it difficult for the patient to get treated. Simultaneously, the patients become drug resistant also as they have to take the medicines for a very long period of time. This results in the body getting adjusted to the drug, and very less improvement is noticed as a result. Researches have proved that treatment for this disorder gives the best results when they are tailored specifically as per the requirements of each individual. The most common modes of treatments are medication and therapy. Till recently, the mainline pharmacological treatments have been pimozide, which is a typical antipsychotic approved for treating Tourette's syndrome, and atypical antipsychotics like risperidone and clozapine.

Treating this disorder can be tough because those individuals who are affected are not likely, or even able, to see that their beliefs are tenuous. Comparatively, few of the affected people seek treatment by their own will, and they may find it difficult to engage successfully in therapy. Non-pharmacological treatments that have shown some degree of efficacy are electroconvulsive therapy (ECT), supportive psychotherapy, family and environment therapy, rehousing, risk management and treating underlying disorders in cases of secondary erotomania. ECT may help in the temporary remission of delusional beliefs; antipsychotics help attenuate delusions and reduce agitation or associated dangerous behaviours, and SSRIs may be used to treat secondary depression.

In this disorder, there is some evidence that pimozide has superior efficacy as compared to other antipsychotics. Psychosocial psychiatric interventions can help enhance the quality of life by allowing some social functioning, and treating comorbid disorders occupies a very important place during the treatment of secondary erotomania.

Other than pharmacological treatments, some non-pharmacological treatment methods are also there which prove to be important in the treatment of this syndrome. Amongst them, family therapy, adjustment of socio-environmental factors and replacing delusions with something positive may be beneficial to all. In maximum cases, harsh confrontation should be avoided. Structured risk assessment helps to manage risky behaviours in those individuals more likely to engage in actions that include violence, stalking and crime. For particularly troublesome cases, neuroleptics and enforced separation may be moderately effective. Priorities should focus on maintaining social function, minimizing the risk of problematic behaviour and improving the affected person's quality of life. It may also be helpful to provide social skills training and to provide practical help in dealing with any problems stemming from erotomania.

Apart from the classic modes of treatment, as the situations are changing and exposure to social networking sites is unavoidable, thus the treatment mechanisms should also employ the strategies needed to help people decrease their social media use. Clinicians should enquire about the pattern of social media use when taking the clinical history of the client, and immediate action should be taken to reduce the chances of such behaviour. Similarly, people should be made aware of the information which they should avoid revealing on social media. In addition, more research should be conducted in this area in order to explore the interplay between social media and erotomanic delusions.

Successful symptom management will focus on treating the underlying disorder and may include medications, therapy and hospitalization. Any or all of these approaches can be applied, depending on the person concerned and the underlying causes. Therapy should help the affected person to comply with an agreed treatment plan and to educate them about their illness.

Hospitalization may be needed if the affected person becomes a danger to themselves, to the object of their affection or to anyone else. Antipsychotic medication may control symptoms effectively and can be prescribed for the underlying disorder. Medication and psychotherapy can be used together. The role that social media plays in any problematic behaviour should be considered when developing a treatment plan.

**Current perspective:** Erotomania is a type of delusional disorder. Other types include delusions of persecution, grandiosity or jealousy. Recent researches have concluded that an extensive use of social media may potentially cause or exacerbate erotomania. Social media eliminates some of the barriers between unacquainted people and can easily be used to observe, contact, stalk and otherwise harass people who would previously have been completely inaccessible. Social media platforms can also reduce the level of privacy of individuals, which can make stalking behaviour much easier. A case study was reported by Faden et al. [28] of a 24-year-old male college student who used social media to stalk a female college student which resulted in his suspension from school and hospitalization. He was diagnosed with delusional disorder, erotomanic type. This case demonstrates that social media can act as a triggering factor of this disorder. Social networking has become a necessity nowadays; thus communication with the object of attention has become easier.

Many a times, girls in the adolescent phase go through different kinds of psychological and physiological changes. They experience attraction towards the opposite gender and want to experience affection from them. Nowadays, access to the Internet and social media has become very easy. Thus, it has led the teens to get information about the celebrity individuals, especially the movie stars very conveniently. When the teens are going through this tumultuous phase of change, the easy access to celebrity's lives can create a feeling of being in love with some celebrity very easily. Some adolescents tend to accept this as an infatuation and forget everything. But some are unable to pass through this phase and start believing that their love is real and mutual. Gradually, it reaches to the delusional level and ultimately ends up in erotomania.

**Forensic aspects of erotomania:** In general, women do not flamboyantly act out their erotomanic delusions, although a well-known American film of the 1970s, Play Misty for Me, describes in fictional terms the dangerous outcome of erotomania occurring in a female. Less dramatic but nonetheless disturbing instances do sometimes occur in real life, to the annoyance, alarm and distress of the object

#### *De Clerambault Syndrome: Current Perspective DOI: http://dx.doi.org/10.5772/intechopen.92121*

of the deluded individual's attention; nowadays, when male professionals are under so much moral pressure to guard against inappropriate sexual behaviour towards clients, it can be devastating if a deluded woman publicly declares that a doctor, a counsellor, a university teacher or someone else has been demonstrating strong erotic feelings towards her. If the deluded individual has a non-deteriorated personality, totally believes her own story and presents her claims as vehemently and persistently as such people do, it may be almost impossible to get the public to believe that what she is saying is untrue. Real unrequited love is bad enough: delusional unrequited love can be impossible. Taylor et al. [5] studied a group of males charged with antisocial behaviour, including persistent unwelcomed importuning of women, and were able to identify cases of erotomania amongst these. Often, they were initially diagnosed as schizophrenic, but closer examination sometimes suggested the presence of paranoia/delusional disorder. The same researchers noted that several patients exhibited quite grandiose behaviours, a common feature of delusional disorder which makes it especially difficult to engage in logical discussion with the person about his false belief or to persuade him to change his behaviour. None of these particular cases had behaved violently towards their victims, but their unremitting harassment often caused the women involved to feel threatened. Goldstein [29] has described cases of severely aggressive, erotomanic behaviour in males, some of whom gained widespread public notoriety. One of these was the young man who attempted to assassinate Ronald Reagan when the latter was President of the United States, apparently believing that this would gain the attention of a well-known female film star, towards whom he entertained erotic delusional feelings. Amongst the other cases Goldstein describes, murder, serious assault, kidnapping and severe harassment occurred. In these individuals the underlying diagnoses were varied but mostly fell within the categories of delusional disorder or paranoid schizophrenia. Goldstein proposes that the changing role of women in society and their higher public profile may act as a stimulus to male erotomania, possibly making the phenomenon more common, but that is hypothetical.

Although the origins of erotomania can be traced to the time of Hippocrates, and from that time onwards, many efforts have been done by different people to explain the nature and root cause of this disorder, but there is limited information about how this disorder, which was first described by De Clerambault, began its course and treatment.
